University of Groningen
Association Between Psychotic Experiences and Subsequent Suicidal Thoughts and
Behaviors
Bromet, Evelyn J; Nock, Matthew K; Saha, Sukanta; Lim, Carmen C W; Aguilar-Gaxiola,
Sergio; Al-Hamzawi, Ali; Alonso, Jordi; Borges, Guilherme; Bruffaerts, Ronny; Degenhardt,
Louisa
Published in:
Jama psychiatry
DOI:
10.1001/jamapsychiatry.2017.2647
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Bromet, E. J., Nock, M. K., Saha, S., Lim, C. C. W., Aguilar-Gaxiola, S., Al-Hamzawi, A., Alonso, J.,
Borges, G., Bruffaerts, R., Degenhardt, L., de Girolamo, G., de Jonge, P., Florescu, S., Gureje, O., Haro, J.
M., He, Y., Hu, C., Karam, E. G., Kovess-Masfety, V., ... World Health Organization World Mental Health
Survey Collaborators (2017). Association Between Psychotic Experiences and Subsequent Suicidal
Thoughts and Behaviors: A Cross-National Analysis From the World Health Organization World Mental
Health Surveys. Jama psychiatry, 74(11), 1136-1144. https://doi.org/10.1001/jamapsychiatry.2017.2647
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Association Between Psychotic Experiences
and Subsequent Suicidal Thoughts and Behaviors
A Cross-National Analysis From the World Health Organization
World Mental Health Surveys
Evelyn J. Bromet, PhD; Matthew K. Nock, PhD; Sukanta Saha, PhD; Carmen C. W. Lim, MSc; Sergio Aguilar-Gaxiola, MD, PhD; Ali Al-Hamzawi, MD; Jordi Alonso, MD, PhD; Guilherme Borges, ScD; Ronny Bruffaerts, PhD; Louisa Degenhardt, PhD; Giovanni de Girolamo, MD; Peter de Jonge, PhD; Silvia Florescu, MD, PhD; Oye Gureje, MD, DSc; Josep M. Haro, MD, PhD; Yanling He, MD; Chiyi Hu, MD, PhD; Elie G. Karam, MD;
Viviane Kovess-Masfety, PhD, MD; Sing Lee, MBBS; Jean-Pierre Lepine, MD; Zeina Mneimneh, PhD; Fernando Navarro-Mateu, MD, PhD; Akin Ojagbemi, PhD; José Posada-Villa, MD; Nancy A. Sampson, BA; Kate M. Scott, PhD; Juan C. Stagnaro, MD, PhD; Maria C. Viana, MD, PhD;
Miguel Xavier, MD, PhD; Ronald C. Kessler, PhD; John J. McGrath, PhD, MD; for the World Health Organization World Mental Health Survey Collaborators
IMPORTANCE
Community-based studies have linked psychotic experiences (PEs) with
increased risks of suicidal thoughts and behaviors (STBs). However, it is not known if these
associations vary across the life course or if mental disorders contribute to these associations.
OBJECTIVETo examine the temporal association between PEs and subsequent STBs across
the life span as well as the influence of mental disorders (antecedent to the STBs) on these
associations.
DESIGN, SETTING, AND PARTICIPANTS
A total of 33 370 adult respondents across 19 countries
from the World Health Organization World Mental Health Surveys were assessed for PEs,
STBs (ie, ideation, plans, and attempts), and 21 DSM-IV mental disorders. Discrete-time
survival analysis was used to investigate the associations of PEs with subsequent onset
of STBs.
MAIN OUTCOMES AND MEASURES
Prevalence and frequency of STBs with PEs, and odds ratios
and 95% CIs.
RESULTS
Of 33 370 included participants, among those with PEs (n = 2488), the lifetime
prevalence (SE) of suicidal ideation, plans, and attempts was 28.5% (1.3), 10.8% (0.7), and
10.2% (0.7), respectively. Respondents with 1 or more PEs had 2-fold increased odds of
subsequent STBs after adjusting for antecedent or intervening mental disorders (suicidal
ideation: odds ratio, 2.2; 95% CI, 1.8-2.6; suicide plans: odds ratio, 2.1; 95% CI, 1.7-2.6; and
suicide attempts: odds ratio, 1.9; 95% CI, 1.5-2.5). There were significant dose-response
relationships of number of PE types with subsequent STBs that persisted after adjustment for
mental disorders. Although PEs were significant predictors of subsequent STB onset across
all life stages, associations were strongest in individuals 12 years and younger. After
adjustment for antecedent mental disorders, the overall population attributable risk
proportions for lifetime suicidal ideation, plans, and attempts associated with temporally
prior PEs were 5.3%, 5.7%, and 4.8%, respectively.
CONCLUSIONS AND RELEVANCE
Psychotic experiences are associated with elevated odds of
subsequent STBs across the life course that cannot be explained by antecedent mental
disorders. These results highlight the importance of including information about PEs in
screening instruments designed to predict STBs.
JAMA Psychiatry. 2017;74(11):1136-1144. doi:10.1001/jamapsychiatry.2017.2647
Published online August 30, 2017.
Supplemental content
Author Affiliations: Author affiliations are listed at the end of this article.
Group Information: The WHO World Mental Health Survey Collaborators are listed at the end of this article. Corresponding Author: John J. McGrath, PhD, MD, Queensland Brain Institute, University of Queensland, QBI Bldg 79, Brisbane, QLD 4072, Australia (j.mcgrath@uq.edu.au).
P
rior studies suggest that psychotic experiences (PEs) are associated with an elevated risk of suicidal thoughts and behaviors (STBs). A 2016 meta-analysis by Honings et al1based on 21 studies reported a 3-fold increased risk of STBs in people with PEs (odds ratio [OR], 3.2; 95% CI, 2.3-4.4). Other studies have doc-umented a significant dose-response relationship between the number of PEs and increased odds of STBs.2-5
Worry-ingly, prospective studies of school-aged children have reported strong associations between PEs and suicide attempts, with children with PEs having an approximately 11-fold increased odds of suicide attempts during the follow-ing 12 months (OR, 11.3; 95% CI, 4.4-28.6) compared with those without PEs.6
Despite the growing body of evidence linking the pres-ence of PEs with STBs, several research questions warrant closer attention. First, there is considerable variation in effect size estimates for these associations across studies, likely owing to differences in methods and analysis.1,7,8Thus, it
would be informative to examine these associations across different sites using similar methods. Second, prior studies have documented that most common mental disorders are associated with increased odds of both PEs9
and STBs.10-12
However, it is unclear whether the presence of mental disor-ders explains the associations of PEs with subsequent STBs.13
Third, although it has generally been assumed that mental disorders could increase the risk of each of 3 main STB out-comes (ie, ideation, plans, and attempts), recent studies have shown that only a subset of those with ideation also have sui-cide plans and attempts.14-16We examine the role of PEs with
respect to the odds of transitioning between ideation, plans, and attempts. Fourth, there is evidence to suggest that the association between PEs and STBs may be stronger in samples based on children6compared with estimates based
on adult samples.1Thus, it would be of interest to examine if
the strength of the association between PEs and STBs differed across age groups within one study. If children and/or adolescents with PEs are differentially prone to STBs compared with older age groups, then this could have impor-tant clinical implications for screening in pediatric and adolescent settings.6
Fifth, there is considerable uncertainty about the population attributable risk proportions (PARPs) for STBs that are associated with PEs. For example, DeVylder et al1 6 reported that about 29% of suic ide attempts
were attributable to PEs among US adults. Kelleher et al6
have found that 56% to 75% of suicide attempts among adolescents aged 13 to 16 years were attributable to PEs (however, these estimates were imprecise; OR, 67.50; 95% CI, 11.41-399.21). Accurate and age-range specific estimates of these PARPs are important for policy-making and prevention purposes.
Specifically, we aimed to examine the association between PEs (and related PE type and frequency metrics) and subsequent STBs across the life span and the influence of mental disorders on these associations. We also exam-ined the associations between PEs, suicide plans and attempts among individuals with suicidal ideation, and the PARPs of various STBs.
Method
Samples
The data were derived from 19 WHO World Mental Health (WMH) surveys, a coordinated set of community surveys ad-ministered in probability samples of adult respondents (18 years and older) in countries throughout the world17
(eTable 1 in the
Supplement). The weighted (by sample size) average re-sponse rate across the 19 surveys was 72.3%, with the highest response rate in Iraq (95.2%) and the lowest in France (45.9%). Further information on details of the procedure and the as-sessment of mental disorders can be found in the eMethods in theSupplement. A human subjects review board or ethics committee approved the survey protocol in each country (eTable 2 in theSupplement), and all respondents gave in-formed consent; the mode of consent (written vs oral) varied by survey.
Measures
Psychotic Experiences
The Composite International Diagnostic Interview Psychosis Module included questions about 6 PE types—2 related to hal-lucinatory experiences and 4 related to delusional experi-ences. We excluded PEs experienced while dreaming, half-asleep, or under the influence of alcohol or drugs (eTable 3A and B in theSupplement). In this article, we present esti-mates of STBs for “Any PEs” only (ie, not individual types of PEs). In addition, we included 2 key PE variables: (1) number of PE types; and (2) an annualized frequency metric based on the frequency of PE episodes (ie, the count of PE occurrences per year). We derived the latter by dividing the total number of PE episodes by the time since onset of the first PE (age at interview minus age at onset plus 1 in order to avoid zero as a denominator). Age at onset of PEs was also assessed. Suicidality
Lifetime STBs were assessed using the Composite Interna-tional Diagnostic Interview Suicidality Module.17Separate
questions were asked about the lifetime occurrence of sui-cidal ideation (“Have you ever seriously thought about com-mitting suicide?”), suicide plans (“Have you ever made a plan for committing suicide?”), and suicide attempt (“Have you ever
Key Points
QuestionAre psychotic experiences associated with subsequent suicidal thoughts and behaviors (STBs), and do mental disorders (antecedent to the STBs) contribute to these associations? FindingsBased on 33 370 adult survey respondents drawn from 19 countries, those with psychotic experiences had 2-fold increased odds of subsequent STBs (after adjusting for mental disorders). Psychotic experiences were predictors of subsequent STB onset across all life stages; however, the strength of the association was strongest in individuals 12 years and younger. MeaningScreening for psychotic experiences may assist in the prediction of subsequent STBs.
Psychotic Experiences and Suicidal Thoughts and Behaviors Original Investigation Research
attempted suicide?”). Information on the age at first occur-rence for each of these outcomes was obtained retrospec-tively. Consistent with our goals of examining associations of PE with a continuum of suicidal behaviors, we considered each of these 3 primary outcomes in the total sample. In addition, we examined 3 secondary nested STB outcomes: (1) suicide plans among respondents with ideation; (2) suicide attempts among those with both ideation and a plan (ie, planned at-tempts); and (3) suicide attempts among respondents with ide-ation but without a plan (ie, unplanned attempts).
Statistical Analysis
The predictive associations of temporally prior PEs with each STB outcome were estimated using discrete-time survival mod-els, with person-year as the unit of analysis. A person-year data set was constructed, where each year in the life of each re-spondent (up to and including the age of STB onset or age at interview, whichever came first) was treated as a separate ob-servational record, with the year of STB onset coded as 1 and earlier years coded as 0. Psychotic experiences were coded as 1 a year after the first PE onset to ensure that a PE occurring in the same year as STBs did not count as a predictor. We first es-timated models of PE and subsequent STBs adjusting for re-spondent’s age at time of interview, sex, person-year dum-mies, and country. In addition, we built models adjusted for age at time of interview, sex, person-year dummies, country, and 21 antecedent mental disorders (ie, mental disorders that had onsets prior to the STBs) to examine the influence of men-tal disorders on the association between PEs and STBs. The joint significance test and test for linear trend were computed. We also conducted a post hoc analysis stratified by mental illness (yes/no) in examining whether the association between PEs and STBs was observed in both the groups.
Next, we reestimated the associations between PEs and subsequent STBs after stratifying the sample into 4 life course stages: childhood (12 years and younger), adoles-cence (aged 13-19 years), young adulthood (aged 20-29 years), and later adulthood (30 years and older). This
allowed us to examine whether the associations varied across the life course and the strength of association (in early vs later years of life), given previous findings of large effect sizes among adolescents (ORs >10).6,18
Finally, PARPS were calculated by converting the ORs obtained from the survival models as approximation of relative risk based on the assumption that the survival coefficients represented causal effects.19
As the WMH data are both clustered and weighted, the de-sign-based Taylor series linearization implemented in SUDAAN software (RTI International) was used to estimate the SEs and evaluate the statistical significance of the coefficients. Sur-vival coefficients and their SEs were exponentiated to gener-ate ORs and 95% CIs. All statistical tests (Wald χ2based on
dis-crete-time survival models) were evaluated using 2-sided tests. Statistical significance was set at P<.05.
Results
Prevalence of STBs
The lifetime prevalence (SE) of suicidal ideation, plans, and attempts in all respondents was 9.2% (0.2), 3.1% (0.1), and 2.8% (0.1), respectively (Table 1). Among 5106 individuals with suicidal ideation, 2000 (33.6%; SE, 0.9) reported a cide plan. Among the subset of 2000 individuals with sui-cidal ideation with a plan, the prevalence of suicide attempts was 55.5% (SE, 1.5). Among the subset of 3106 individuals with suicidal ideation without a plan, the prevalence of sui-cide attempts was 17.0% (SE, 0.9). (The proportions for the nested suicide outcomes reflect different denominators; eTable 4 in theSupplement.) The lifetime prevalence of STBs was substantially higher among those with PEs com-pared with those without PEs (Table 1). Specifically, among respondents with PEs, the prevalence (SE) of suicidal ide-ation, plans, and attempts was 28.5% (1.3), 10.8% (0.7), and 10.2% (0.7), respectively, compared with 8.0% (0.2), 2.6% (0.1), and 2.3% (0.1) for respondents without PEs.
Table 1. Lifetime Prevalence of Suicidal Ideation, Plans, and Attempts
Characteristic
Ideation Plans Attempts
No./Total No. (%)a SE No./Total No. (%)a SE No./Total No. (%)a SE
STB prevalence 5106/33 370 (9.2) 0.2 2000/33 370 (3.1) 0.1 1771/33 370 (2.8) 0.1 PE status
No PE 4165/30 882 (8.0) 0.2 1583/30 882 (2.6) 0.1 1388/30 882 (2.3) 0.1
Any PE 941/2488 (28.5) 1.3 417/2488 (10.8) 0.7 383/2488 (10.2) 0.7
No. of PE types (in those with PEs)
Exactly 1 PE type 571/1706 (23.8) 1.4 236/1706 (8.6) 0.7 219/1706 (8.0) 0.7 Exactly 2 PE types 247/566 (35.4) 3.4 111/566 (12.8) 1.6 98/566 (12.1) 1.6
≥3 PE types 123/216 (57.5) 4.9 70/216 (28.8) 4.2 66/216 (27.9) 4.4
PE annualized frequency metric (in those with PEs)b
≤0.3 Episodes/y 425/1259 (25.7) 1.9 183/1259 (9.6) 1.0 167/1259 (9.0) 1.0 >0.3 Episodes/y 516/1229 (31.7) 1.8 234/1229 (12.2) 1.1 216/1229 (11.5) 1.0 Abbreviations: PE, psychotic experience; STB, suicidal thoughts and behaviors.
aNumerators refer to the number of individuals with each suicidal outcome.
Denominators refer to the number of individuals in the total sample or in the
sample of those with/without PEs. Estimates are based on weighted data.
bAnnualized PE (frequency of PE per year) = frequency of PE
Associations Between Lifetime PEs and Subsequent Onset
of STBs
Compared with those without PEs, those with any PEs had 3-fold the odds of a subsequent first onset of each STB out-come after adjusting for demographic factors (Table 2), with adjusted ORs for suicidal ideation, plans, and attempts of 3.0 (95% CI, 2.6-3.6), 3.4 (95% CI, 2.8-4.1), and 3.1 (95% CI, 2.4-3.9), respectively. Overall, the PE-type metric was sig-nificant in predicting 3 STBs (χ2ranged between 137.5 and
256.2; P < .001). The tests for linear trend were also signifi-cant, with χ2ranging between 15.0 and 24.7, indicating that
there was a dose-response relationship. The ORs for STBs among those experiencing 3 or more PE types ranged from 7.1 for ideation (95% CI, 4.9-10.3) to 11.1 for plans (95% CI, 7.1-17.4). There was also a 3-fold to 4-fold increased odds of various STBs in those with more frequent annualized PEs (more than 0.3 episodes per year) compared with those with less frequent annualized PEs (0.3 episodes or less per year), with ORs ranging from 3.0 for attempts (95% CI, 2.3-4.1) to 3.8 for plans (95% CI, 2.9-5.1).
When we adjusted for 21 antecedent mental disorders, the effect sizes attenuated but remained statistically signifi-cant. After adjustment, those with any PEs had twice the odds of subsequent onset of all 3 STBs. The significant dose-response relationship between higher PE frequency metrics and STBs also persisted.
When we restricted the analysis to the subset with sui-cidal ideation, the associations of any PEs with suicide plans and suicide attempts were not significant, indicating that PEs are associated with increased odds of suicidal ideation but not with an increased odds of planning or attempting suicide among those reporting suicide ideation (eTable 5 in the Supple-ment). As a post hoc analysis, we also repeated the analysis stratified by mental disorders (yes/no). While the 95% CIs were wider in the subgroup with no mental disorders, the general pattern of findings persisted (eTable 6 in theSupplement).
Associations Between Lifetime PEs and Subsequent Onset
of STBs Across 4 Life Course Stages
Table 3 shows the associations between PEs and subsequent on-set of STBs in 4 life course stages. In the basic demographic ad-justment models, we found strong and significant associations between occurrence of PEs and subsequent onset of STBs in all 4 life course stages (childhood, adolescence, early adulthood, and later adulthood). The effect sizes were significantly higher in childhood compared with other age groups (ideation: χ2
= 14.7;
P < .001; plans: χ2= 17.6; P < .001; and attempts: χ2= 8.8;
P = .003). The ORs for suicidal ideation, plans, and attempts in
childhood were 4.0 (95% CI, 2.3-6.8), 7.8 (95% CI, 3.4-17.9), and 5.4 (95% CI, 2.6-11.3), respectively. When adjusted for anteced-ent manteced-ental disorders, the pattern of associations remained sig-nificant though the effect sizes were attenuated.
Table 2. Associations Between Lifetime PEs and Subsequent Onset of Suicidal Ideation, Plans, and Attempts, With and Without Adjustment for Antecedent Mental Disorders
Characteristic
OR (95% CI)
Ideation Plans Attempts
Basic Demographic Adjustmenta Adjusted for Antecedent Mental Disordersb Basic Demographic Adjustmenta Adjusted for Antecedent Mental Disordersb Basic Demographic Adjustmenta Adjusted for Antecedent Mental Disordersb PE status Any PE 3.0 (2.6-3.6)c 2.2 (1.8-2.6)c 3.4 (2.8-4.1)c 2.1 (1.7-2.6)c 3.1 (2.4-3.9)c 1.9 (1.5-2.5)c No. of PE types Exactly 1 PE type 2.5 (2.0-3.1)c 1.9 (1.5-2.3)c 2.6 (2.0-3.3)c 1.8 (1.4-2.3)c 2.3 (1.7-3.2)c 1.6 (1.1-2.2)c Exactly 2 PE types 3.7 (2.7-4.9)c 2.5 (1.8-3.3)c 3.6 (2.5-5.2)c 2.1 (1.5-3.1)c 3.3 (2.2-5.0)c 1.9 (1.2-3.0)c ≥3 PE types 7.1 (4.9-10.3)c 4.1 (2.9-5.9)c 11.1 (7.1-17.4)c 5.2 (3.1-8.7)c 10.3 (6.2-17.2)c 4.0 (2.2-7.3)c
Joint significance of the PE type measures
χ2
3 256.2 112.9 203.1 63.7 137.5 30.5
P value <.001 <.001 <.001 <.001 <.001 <.001 Difference in the ORs of
the PE type measures χ2
2 24.3 14.7 32.4 15.0 26.0 7.6
P value <.001 .001 <.001 .001 <.001 .02
Test for linear trend χ2
1 15.0 13.2 20.6 14.3 24.7 14.6
P value <.001 <.001 <.001 <.001 <.001 <.001 PE frequency metric
>0.3 Episodes/y 3.5 (2.8-4.3)c 2.4 (2.0-3.0)c 3.8 (2.9-5.1)c 2.3 (1.7-3.0)c 3.0 (2.3-4.1)c 1.8 (1.3-2.5)c
Abbreviations: OR, odds ratio; PE, psychotic experience; STB, suicidal thoughts and behaviors.
aPsychotic experience (any PE, number of PE type, and frequency metric) was
used as a predictor of STB outcomes in separate discrete-time survival models. These models control for age cohorts, sex, person-year dummies, and country.
bThese models additionally control for 21 other antecedent mental disorders. c
Statistically significant at the P < .05 level (Wald χ2
based on discrete-time survival models) using 2-sided tests.
Psychotic Experiences and Suicidal Thoughts and Behaviors Original Investigation Research
PARPs Between PEs and STBs
The overall PARPs for suicidal ideation, plans, and attempts ranged between 8.4% and 11.0% (Table 4) in the basic demo-graphic adjustment models. After adjustments for anteced-ent manteced-ental disorders, the overall PARPs were smaller, rang-ing from 4.8% to 5.7%. When examined across the life course, compared with older age groups, children 12 years and younger consistently had the highest PARPs (9.0%, 20.0%, and 11.1% for suicidal ideation, plans, and attempts, respectively) after adjustment for antecedent mental disorders.
Discussion
The results reported here are based on, to our knowledge, the largest and most detailed study of PEs and STBs reported to date. We found that community respondents who reported PEs had 2-fold increased odds of subsequent suicidal ideation, plans, and attempts after adjustment for antecedent mental disorders. These estimates are broadly consistent with sev-eral longitudinal studies1,5,13,20but slightly lower than the
pooled estimate from a 2016 meta-analysis.1We also found a
dose-response relationship between (1) higher numbers of PE
types (in keeping with previous literature)2-5
and (2) higher an-nualized PE frequency with subsequent STBs. Additionally, these results shed new light on 4 issues. First, the association between PEs and STBs persisted after adjustment for anteced-ent manteced-ental disorders. Second, among the subset of respon-dents reporting suicidal ideation, PEs did not contribute sig-nificantly to increased odds of subsequent suicide plans or attempts. Third, the association between PEs and STBs was most prominent in children 12 years and younger. Fourth, PEs accounted for an appreciable proportion of STBs (9%-20%) dur-ing childhood, even when adjusted for antecedent mental dis-orders. We discuss each of these in turn.
First, although the association between PEs and STBs was attenuated after adjustment for 21 antecedent mental disorders, appreciable ORs (at least 2-fold) were still found between PEs and STBs. These finding are consistent with previous studies1,3,21and
lend weight to the hypothesis that the experience of PEs, even in the absence of mental disorders, may be sufficient to influence the subsequent onset of STBs. This is an important finding from a clinical point of view because it suggests that PEs may be a pre-dictor of subsequent STBs even in individuals who do not meet criteria for mental disorders. In keeping with a 2017 commentary,22we do not propose that the presence of isolated
Table 4. Population Attributable Risk Proportions of Suicidal Ideation, Plans, and Attempts Owing to Psychotic Experiences in Each of 4 Life Course Stages, With and Without Adjustment for Antecedent Mental Disordersa
Category
Population Attributable Risk Proportions, % Childhood (≤12 y) Adolescence (Aged 13-19 y) Young Adulthood (Aged 20-29 y) Later Adulthood (≥30 y) Overall Basic Demographic Adjustments
Ideation 14.1 10.6 9.7 8.2 8.4
Plans 27.6 13.6 11.0 8.5 11.0
Attempts 19.9 10.0 10.7 10.8 10.0
Adjusted for Antecedent Mental Disorders
Ideation 9.0 6.9 6.5 4.6 5.3
Plans 20.0 7.6 6.3 3.6 5.7
Attempts 11.1 4.8 5.5 4.3 4.8
a
Population attributable risk proportions = (p × (relative risk − 1)) / (p × (relative risk − 1) + 1), where p indicates the proportion of respondents in the sample with psychotic experiences. Table 3. Associations Between Lifetime Psychotic Experiences and Subsequent Onset of Suicidal Ideation, Plans, and Attempts in Each
of 4 Life Course Stages, With and Without Adjustment for Antecedent Mental Disorders
Category
OR (95% CI)
Test for the Significance of the Slope Differences Across 4 Life Course Stages
Test for Significant Differences Between Childhood and Other Age Groups Childhood (≤12 y) Adolescence (Aged 13-19 y) Young Adulthood (Aged 20-29 y) Later Adulthood (≥30 y) χ2 3 P Value χ21 P Value
Basic Demographic Adjustmentsa
Ideation 4.0 (2.3-6.8) 3.3 (2.6-4.2) 3.0 (2.3-3.9) 2.7 (2.0-3.6) 16.4 <.001 14.7 <.001 Plans 7.8 (3.4-17.9) 3.9 (2.9-5.3) 3.2 (2.3-4.5) 2.7 (1.8-3.9) 20.6 <.001 17.6 <.001 Attempts 5.4 (2.6-11.3) 3.0 (2.1-4.3) 3.1 (2.1-4.6) 3.1 (1.9-5.1) 10.8 .003 8.8 .01 Adjusted for Antecedent Mental Disordersb
Ideation 2.8 (1.5-5.0) 2.4 (1.8-3.1) 2.3 (1.8-3.0) 1.9 (1.4-2.6) 21.2 <.001 19.2 <.001 Plans 5.5 (2.2-13.8) 2.5 (1.8-3.5) 2.2 (1.6-3.1) 1.7 (1.1-2.5) 26.1 <.001 22.2 <.001 Attempts 3.2 (1.4-7.6) 1.9 (1.3-2.9) 2.0 (1.3-3.1) 1.8 (1.0-3.2) 16.5 <.001 14.0 <.001 Abbreviation: OR, odds ratio.
aAny psychotic experience was used as a predictor of suicidal thoughts and
behaviors outcomes in a discrete-time survival model controlling for age
cohorts, sex, person-year dummies, and country.
PEs is sufficient to identify individuals with an ultrahigh risk of later transition to psychotic disorder; however, these individu-als do have an increased risk of a range of other adverse outcomes, including STBs. Psychotic experiences and suicidality may share common risk factors (eg, traumatic life events or family history). Previous research found that the association between PEs and STBs persisted after adjusting for trauma and experiencing harm.3,4
We hypothesize that as PEs are associated with both psy-chological distress23and disability,24,25these factors may be
suf-ficient to contribute to the emergence of subsequent STBs. How-ever, we note that it is conceivable that PEs and STBs may both emerge during a prodromal phase of a later mental disorder (ie, a disorder with an age at onset after prior STBs). Although this analysis is beyond the scope of the current article, such research could further reinforce the clinical utility of routine monitoring of PEs in at-risk samples. Future studies may wish to include mea-sures of disorganized speech, which is a clinical feature of psy-chotic disorder not routinely included in PE assessment.
Second, we demonstrated, to our knowledge for the first time, that although PEs were associated with an overall in-crease in STBs, among those with suicidal ideation, they did not make an additional contribution to the subsequent tran-sition to suicide plans or planned/unplanned attempts. In other words, while those with PEs had an increased odds of each of the 3 STB outcomes (ie, suicidal ideation, suicide plans, and suicide attempts), our findings suggest that the presence of PEs did not alter the odds of transition from suicidal ideation to planned or unplanned attempts. This general pattern is con-sistent with previous research that explored the associations of mental disorders and these nested STB outcomes.11
How-ever, the results are in contrast to DeVylder et al,16
who found that respondents with PEs and suicidal ideation had more than 3-fold increased risk of attempting suicide. This discrepancy may reflect differences in methods related to the use of tem-poral ordering between the variables of interest.
Third, we found that PEs were associated with the subse-quent onset of STBs in each of the 4 life course stages and that this pattern of associations persisted after adjustment for ante-cedent mental disorders. Mindful that PEs have a wide age-at-onset distribution (median [interquartile range], 26 [17-41] years),26
our findings support the hypothesis that PEs are asso-ciated with an increased odds of subsequent STBs regardless of age. However, we confirmed that the association between PEs and STBs was indeed more prominent in childhood, consistent with previous findings based on longitudinal studies.5,6,20,27
While our study was based on adult respondents (18 years and older), it is reassuring to note that the strong association between childhood-onset PEs and STBs has been confirmed in both broad cross-sectionally ascertained samples, like the WMH, and pro-spectively studied adolescent cohorts. Future studies may wish to explore biological and psychosocial factors that could explain why the association between PEs and subsequent STBs is
stron-ger in young children compared with other age groups (eg, a dif-ferential sensitivity to stress28,29).
Finally, we showed that after adjustment for antecedent mental disorders, the overall PARP estimates (between 4.8% and 5.7%) were smaller than previously reported.6,16However, in
chil-dren, the adjusted PARPs (between 9% and 20%) were similar to previously reported PARPs. We recommend caution when in-terpreting PARPs—these estimates assume causality between the variables of interest.19These findings lend weight to the
recom-mendation by Kelleher et al6that clinicians should include PEs
when assessing risk of STBs in young people and that future clini-cal and epidemiologic studies of STBs should include PE-related items in their risk factor battery.
Limitations
The current study has several strengths (large sample size, range of countries, uniform methods for data collection, temporally or-dered variables, etc). However, it is important to note the study limitations. First, although we excluded people who were screened positive for possible psychotic disorders, the WMH sur-veys were administered by lay interviewers, and clinical valida-tion of self-reported diagnoses of psychosis or mania was not available. Second, we also used retrospective reports of age at on-set of the PEs, STBs, and mental disorders; although rigorously obtained,30this is subject to some level of recall bias. However,
we note that 5 prospective studies have confirmed the associa-tion between PEs and subsequent STBs.5,6,20,27,31
Third, the sur-veys were cross-sectional, and without additional follow-up, we were unable to examine the association between PEs and com-pleted suicide. We are aware of 2 prospective community-based studies that explored this question, but both lacked sufficient power (ie, small number of completed suicides) to confidently estimate the influence of PEs on this outcome.20,32Fourth, it will
be of interest to explore if particular types of PEs (eg, hallucina-tions or delusions) are differentially associated with STBs in fu-ture analyses.
Conclusions
We found that PEs were independently associated with sub-sequent STBs regardless of antecedent mental disorders. There were significant dose-dependent relationships between both number of PE types and annualized frequency of PEs with subsequent STBs. The association was found at all ages, with a stronger effect at younger ages, and were associated with appreciable PARPs. From a public health perspective, we speculate that the inclusion of PE items in routine screening tools could improve the prediction of sui-cide risk. Our study lends additional weight to the call for the routine inclusion of PE items when assessing STBs in both research and clinical settings.
ARTICLE INFORMATION
Accepted for Publication: July 11, 2017. Published Online: August 30, 2017. doi:10.1001/jamapsychiatry.2017.2647
Author Affiliations: Department of Psychiatry, Stony Brook University School of Medicine, Stony Brook, New York (Bromet); Psychology Department, Harvard University, Cambridge, Massachusetts (Nock); Queensland Centre for
Mental Health Research, Queensland Brain Institute, The University of Queensland, Brisbane, Queensland, Australia (Saha, Lim); Center for Reducing Health Disparities, University of California-Davis Health System, Sacramento Psychotic Experiences and Suicidal Thoughts and Behaviors Original Investigation Research
(Aguilar-Gaxiola); College of Medicine, Al-Qadisiya University, Diwaniya Governorate, Iraq (Al-Hamzawi); Health Services Research Unit, Institut Hospital del Mar d’Investigacions Mèdiques, Barcelona, Spain (Alonso); Pompeu Fabra University, Barcelona, Spain (Alonso); Centros de Investigación Biomédica en Red en Epidemiología y Salud Pública, Barcelona, Spain (Alonso); National Institute of Psychiatry Ramón de la Fuente, Mexico City, Mexico (Borges); Universitair Psychiatrisch Centrum, Katholieke Universiteit Leuven, Campus Gasthuisberg, Leuven, Belgium (Bruffaerts); National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia (Degenhardt); Unit of Epidemiological and Evaluation Psychiatry, Istituti di Ricovero e Cura a Carattere Scientifico– St John of God Clinical Research Centre, Brescia, Italy (de Girolamo); Developmental Psychology, Department of Psychology, Rijksuniversiteit Groningen, Groningen, the Netherlands (de Jonge); Interdisciplinary Center Psychopathology and Emotion Regulation, Department of Psychiatry, University Medical Center Groningen, Groningen, the Netherlands (de Jonge); National School of Public Health, Management, and Professional Development, Bucharest, Romania (Florescu); Department of Psychiatry, University College Hospital, Ibadan, Nigeria (Gureje); Parc Sanitari Sant Joan de Déu, Centro de Investigación Biomédica en Red en Salud Mental, Universitat de Barcelona, Sant Boi de Llobregat, Barcelona, Spain (Haro); Shanghai Mental Health Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China (He); Shenzhen Institute of Mental Health, Shenzhen Kangning Hospital, Shenzhen, China (Hu); Department of Psychiatry and Clinical Psychology, Faculty of Medicine, St George Hospital University Medical Center, Balamand University, Beirut, Lebanon (Karam); Institute for Development, Research, Advocacy, and Applied Care, Beirut, Lebanon (Karam); Ecole des Hautes Etudes en Santé Publique, Paris Descartes University, Paris, France (Kovess-Masfety); Department of Psychiatry, Chinese University of Hong Kong, Hong Kong (Lee); Hôpital Lariboisière-Fernand Widal, Assistance Publique Hôpitaux de Paris, Universités Paris Descartes-Paris Diderot, INSERM UMR-S 1144, Paris, France (Lepine); Survey Research Center, University of Michigan, Ann Arbor (Mneimneh); Unidad de Docencia, Investigación y Formación en Salud Menta, Subdirección General de Planificación, Innovación y Cronicidad, Servicio Murciano de Salud, Instituto Murciano de Investigación Biosanitaria–Arrixaca, Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública–Murcia, Murcia, Spain (Navarro-Mateu); Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria (Ojagbemi); Faculty of Social Sciences, Colegio Mayor de Cundinamarca University, Bogota, Colombia (Posada-Villa); Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts (Sampson, Kessler); Department of Psychological Medicine, University of Otago, Dunedin, Otago, New Zealand (Scott); Departamento de Psiquiatría y Salud Mental, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina (Stagnaro); Department of Social Medicine, Federal University of Espírito Santo, Vitoria, Brazil (Viana); Chronic Diseases Research Center, Department of Mental Health, Faculdade de Ciências Médicas,
Universidade Nova de Lisboa, Campo dos Mártires da Pátria, Lisbon, Portugal (Xavier); Queensland Centre for Mental Health Research, University of Queensland, Brisbane, Queensland, Australia (McGrath); Queensland Brain Institute, University of Queensland, Brisbane, Queensland, Australia (McGrath); National Centre for Register-Based Research, Aarhus School of Business and Social Sciences, Aarhus University, Aarhus, Denmark (McGrath).
Author Contributions: Dr Kessler had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Bromet, Lim,
Al-Hamzawi, Haro, Karam, Mneimneh, Xavier, Kessler, McGrath.
Acquisition, analysis, or interpretation of data:
Bromet, Nock, Saha, Lim, Aguilar-Gaxiola, Alonso, Borges, Bruffaerts, Degenhardt, de Girolamo, de Jonge, Florescu, Gureje, Haro, He, Hu, Kovess-Masfety, Lee, Lepine, Mneimneh, Navarro-Mateu, Ojagbemi, Posada-Villa, Sampson, Scott, Stagnaro, Viana, Kessler, McGrath.
Drafting of the manuscript: Bromet, Nock, Saha,
Lim, McGrath.
Critical revision of the manuscript for important intellectual content: Bromet, Saha, Lim,
Aguilar-Gaxiola, Al-Hamzawi, Alonso, Borges, Bruffaerts, Degenhardt, de Girolamo, de Jonge, Florescu, Gureje, Haro, He, Hu, Karam, Kovess-Masfety, Lee, Lepine, Mneimneh, Navarro-Mateu, Ojagbemi, Posada-Villa, Sampson, Scott, Stagnaro, Viana, Xavier, Kessler, McGrath.
Statistical analysis: Saha, Lim, Sampson, Stagnaro,
Kessler, McGrath.
Obtained funding: Bromet, Nock, Aguilar-Gaxiola,
Alonso, Bruffaerts, Gureje, Kovess-Masfety, Posada-Villa, McGrath.
Administrative, technical, or material support:
Aguilar-Gaxiola, Bruffaerts, de Girolamo, He, Hu, Lee, Lepine, Mneimneh, Posada-Villa.
Supervision: Aguilar-Gaxiola, de Girolamo, Karam,
Kovess-Masfety, Navarro-Mateu, Sampson, McGrath.
Conflict of Interest Disclosures: In the past 3 years, Dr Kessler has received support for his epidemiological studies from Sanofi Aventis, was a consultant for Johnson & Johnson Wellness and Prevention, and served on an advisory board for the Johnson & Johnson Services Lake Nona Life Project. Kessler is a co-owner of DataStat, a market research firm that carries out health care research. No other disclosures were reported.
Funding/Support: The World Health Organization World Mental Health Survey Initiative is supported by the National Institute of Mental Health (grant R01 MH070884), the John D. and Catherine T. MacArthur Foundation, the Pfizer Foundation, the US Public Health Service (grants R13-MH066849, R01-MH069864, and R01 DA016558), the Fogarty International Center (grant FIRCA R03-TW006481) , the Pan American Health Organization, Eli Lilly and Company, Ortho-McNeil Pharmaceutical, GlaxoSmithKline, and Bristol-Myers Squibb. The Argentina survey—Estudio Argentino de Epidemiología en Salud Mental—is supported by a grant from the Argentinian Ministry of Health (Ministerio de Salud de la Nación). The Colombian National Study of Mental Health is supported by the Ministry of Social Protection. The European Study of the Epidemiology of Mental Disorders project is
funded by the European Commission (contracts QLG5-1999-01042, SANCO 2004123, and EAHC 20081308), the Piedmont Region (Italy), Fondo de Investigación Sanitaria of the Instituto de Salud Carlos III (grant FIS 00/0028), Ministerio de Ciencia y Tecnología (grant SAF 2000-158-CE),
Departament de Salut de Generalitat de Catalunya via Instituto de Salud Carlos III (grants CIBER CB06/02/0046 and RETICS RD06/0011 REM-TAP), and other local agencies and by an unrestricted educational grant from GlaxoSmithKline. Implementation of the Iraq Mental Health Survey and data entry were carried out by the staff of the Iraqi Ministry of Health and Ministry of Planning, with direct support from the Iraqi survey team, with funding from both the Japanese and European Funds through the United Nations Development Group Iraq Trust Fund. The Lebanese Evaluation of the Burden of Ailments and Needs Of the Nation is supported by the Lebanese Ministry of Public Health, the World Health Organization (Lebanon), the National Institute of Health/Fogarty International Center (grant R03 TW006481-01), anonymous private donations to the Institute for Development, Research, Advocacy, and Applied Care, Lebanon, and unrestricted grants from Algorithm, AstraZeneca, Benta, Bella Pharma, Eli Lilly, GlaxoSmithKline, Lundbeck, Novartis, Servier, Phenicia, and Union Pharmaceutique d’Orient. The Mexican National Comorbidity Survey is supported by The National Institute of Psychiatry Ramon de la Fuente (grant INPRFMDIES 4280) and by the National Council on Science and Technology (grant CONACyT-G30544- H), with supplemental support from the PanAmerican Health Organization. Te Rau Hinengaro: The New Zealand Mental Health Survey is supported by the New Zealand Ministry of Health, Alcohol Advisory Council, and the Health Research Council. The Nigerian Survey of Mental Health and Wellbeing is supported by the World Health Organization (Geneva), the World Health Organization (Nigeria), and the Federal Ministry of Health of Nigeria. The Peruvian World Mental Health Study is funded by the National Institute of Health of the Ministry of Health of Peru. The Portuguese Mental Health Study is carried out by the Department of Mental Health, Faculty of Medical Sciences, Nova University of Lisbon, with collaboration of the Portuguese Catholic University, and is funded by Champalimaud Foundation, Gulbenkian Foundation, Foundation for Science and Technology, and Ministry of Health. The Romania World Mental Health study projects “Policies in Mental Health Area” and “National Study Regarding Mental Health and Services Use” were carried out by National School of Public Health and Health Services Management, with technical support by Metro Media Transilvania, the National Institute of Statistics–National Centre for Training in Statistics SC, Cheyenne Services, Statistics Netherlands, and were funded by the Ministry of Public Health with supplemental support of Eli Lilly Romania. The São Paulo Megacity Mental Health Survey is supported by the State of São Paulo Research Foundation (Thematic Project Grant 03/00204-3). The Shenzhen Mental Health Survey is supported by the Shenzhen Bureau of Health and the Shenzhen Bureau of Science, Technology, and Information. The US National Comorbidity Survey Replication is supported by the National Institute of Mental Health (grant U01-MH60220) with supplemental support from the National Institute of Drug Abuse, the Substance Abuse and Mental Health Services
Administration, the Robert Wood Johnson Foundation (grant 044708), and the John W. Alden Trust. Dr McGrath received John Cade Fellowship APP1056929 from the National Health and Medical Research Council and Niels Bohr Professorship from the Danish National Research Foundation. Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Group Information: The World Health Organization World Mental Health Survey collaborators are Sergio Aguilar-Gaxiola, MD, PhD (Center for Reducing Health Disparities, University of California-Davis Health System, Sacramento); Ali Al-Hamzawi, MD (College of Medicine, Al-Qadisiya University, Diwaniya Governorate, Iraq); Mohammed Salih Al-Kaisy, MD (Ibn Seena Teaching Hospital, Alkhdhira, Baghdad, Iraq); Jordi Alonso, MD, PhD (Health Services Research Unit, Hospital del Mar Medical Research Institute, Barcelona, Spain); Laura Helena Andrade, MD, PhD (Section of Psychiatric Epidemiology–LIM 23, Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil); Corina Benjet, PhD (Department of Epidemiologic and Psychosocial Research, National Institute of Psychiatry Ramón de la Fuente Muniz, Mexico City, Mexico); Guilherme Borges, ScD (National Institute of Psychiatry Ramón de la Fuente, Mexico City, Mexico); Evelyn J. Bromet, PhD (Department of Psychiatry, Stony Brook University School of Medicine, Stony Brook, New York); Ronny Bruffaerts, PhD (Universitair Psychiatrisch Centrum, Katholieke Universiteit Leuven, Campus Gasthuisberg, Leuven, Belgium); Brendan Bunting, PhD (School of Psychology, Ulster University, Londonderry, United Kingdom); Jose Miguel Caldas de Almeida, MD, PhD (Chronic Diseases Research Center, Department of Mental Health, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal); Graca Cardoso, MD, PhD (Department of Mental Health, Faculdades de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal); Somnath Chatterji, MD (Department of Information, Evidence and Research, World Health Organization, Geneva, Switzerland); Alfredo H. Cia, MD (Anxiety Disorders Center, Buenos Aires, Argentina); Louisa Degenhardt, PhD (National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia); Koen Demyttenaere, MD, PhD (Department of Psychiatry, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium); John Fayyad, MD (Institute for Development, Research, Advocacy and Applied Care, Beirut, Lebanon); Silvia Florescu, MD, PhD (National School of Public Health, Management and Professional Development, Bucharest, Romania); Giovanni de Girolamo, MD (Unit of Epidemiological and Evaluation Psychiatry, Istituti di Ricovero e Cura a Carattere Scientifico–St John of God Clinical Research Centre, Brescia, Italy); Oye Gureje, MD, DSc, FRCPsych (Department of Psychiatry, University College Hospital, Ibadan, Nigeria); Josep Maria Haro, MD, PhD (Parc Sanitari Sant Joan de Déu, Centro de Investigación Biomédica en Red en Salud Mental, Universitat de Barcelona, Sant Boi de Llobregat, Barcelona, Spain); Yanling He, MD (Shanghai Mental Health Center, Shanghai Jiao Tong University, School of Medicine, Shanghai,
China); Hristo Hinkov, MD, PhD (National Center of Public Health and Analyses, Sofia, Bulgaria); Chiyi Hu, MD, PhD (Shenzhen Institute of Mental Health and Shenzhen Kangning Hospital, Shenzhen, China); Yueqin Huang, MD, MPH, PhD (Institute of Mental Health, Peking University, Beijing, China); Peter de Jonge, PhD (Developmental Psychology, Department of Psychology, Rijksuniversiteit Groningen, Groningen, the Netherlands); Aimee Nasser Karam, PhD (Institute for Development, Research, Advocacy, and Applied Care, Beirut, Lebanon); Elie G. Karam, MD (Department of Psychiatry and Clinical Psychology, Faculty of Medicine, St George Hospital University Medical Center, Balamand University, Beirut, Lebanon); Norito Kawakami, MD, DMSc (Department of Mental Health, School of Public Health, The University of Tokyo, Tokyo, Japan); Ronald C. Kessler, PhD (Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts); Andrzej Kiejna, MD, PhD (Wroclaw Medical University, University of Lower Silesia, Wroclaw, Poland); Viviane Kovess-Masfety, MD, PhD (Ecole des Hautes Etudes en Santé Publique, Paris Descartes University, Paris, France); Sing Lee, MBBS (Department of Psychiatry, Chinese University of Hong Kong, Hong Kong); Jean-Pierre Lepine, MD (Hôpital Lariboisière-Fernand Widal, Assistance Publique Hôpitaux de Paris, Universités Paris Descartes-Paris Diderot, INSERM UMR-S 1144, Paris, France); Daphna Levinson, PhD (Mental Health Services, Ministry of Health, Jerusalem, Israel); John McGrath, MD, PhD (Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, Queensland, Australia); Maria Elena Medina-Mora, PhD (National Institute of Psychiatry Ramón de la Fuente, Mexico City, Mexico); Jacek Moskalewicz, PhD (Institute of Psychiatry and Neurology, Warsaw, Poland); Fernando Navarro-Mateu, MD, PhD (Unidad de Docencia, Investigación y Formación en Salud Menta, Subdirección General de Planificación, Innovación y Cronicidad, Servicio Murciano de Salud, Instituto Murciano de Investigación Biosanitaria–Arrixaca, Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública–Murcia, Murcia, Spain); Beth-Ellen Pennell, MA (Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor); Marina Piazza, MPH, ScD (National Institute of Health, Lima, Peru); Jose Posada-Villa, MD (Colegio Mayor de Cundinamarca University, Faculty of Social Sciences, Bogota, Colombia); Kate M. Scott, PhD (Department of Psychological Medicine, University of Otago, Dunedin, Otago, New Zealand); Tim Slade, PhD (National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia); Juan Carlos Stagnaro, MD, PhD (Departamento de Psiquiatría y Salud Mental, Facultad de Medicina, Universidad de Buenos Aires, Argentina); Dan J. Stein, FRCPC, PhD (Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, Republic of South Africa); Margreet ten Have, PhD (Trimbos-Instituut, Netherlands Institute of Mental Health and Addiction, Utrecht, the Netherlands); Yolanda Torres, MPH, DraHC (Center for Excellence on Research in Mental Health, CES University, Medellin, Colombia); Maria Carmen Viana, MD, PhD (Department of Social Medicine, Federal University of Espírito Santo, Vitoria, Brazil); Harvey Whiteford, MBBS, PhD (School of Public Health, University of Queensland, Brisbane, Queensland, Australia);
David R. Williams, MPH, PhD (Department of Society, Human Development, and Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts); and Bogdan Wojtyniak, ScD (Centre of Monitoring and Analyses of Population Health, National Institute of Public Health-National Institute of Hygiene, Warsaw, Poland). A complete list of all within-country and cross-national WMH publications can be found athttp://www.hcp.med .harvard.edu/wmh/.
Disclaimer: The views and opinions expressed in this report are those of the authors and should not be construed to represent the views of the World Health Organization, other sponsoring organizations, agencies, or governments. Additional Contributions: We thank the staff of the World Mental Health Data Collection and Data Analysis Coordination Centres for assistance with instrumentation, fieldwork, and consultation on data analysis.
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